What is the treatment for Gonococcal Conjunctivitis?

Treatment of Gonococcal Conjunctivitis

For adult gonococcal conjunctivitis, administer ceftriaxone 250 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose, combined with saline lavage of the infected eye. 1

Adult Treatment Protocol

Systemic Antibiotic Therapy

• Ceftriaxone 250 mg IM single dose AND azithromycin 1 g orally single dose is the recommended dual therapy for adults 2, 1
• The dual therapy addresses both gonococcal infection and potential chlamydial co-infection, which is common 1
• For cephalosporin-allergic patients, azithromycin 2 g orally as a single dose may be used, though resistance concerns exist 2, 1
• Doxycycline 100 mg orally twice daily for 7 days is an alternative to azithromycin for chlamydial coverage 2

Local Therapy

• Saline lavage of the infected eye should be performed to promote comfort and faster resolution 1
• If corneal involvement is present, add topical antibiotics appropriate for bacterial keratitis 1
• Topical antibiotic therapy alone is inadequate and unnecessary if systemic treatment is administered 2

Critical Management Considerations

• Hospitalization may be necessary for severe gonococcal conjunctivitis to administer parenteral therapy 2
• Daily follow-up is required until resolution, with visual acuity measurement and slit-lamp biomicroscopy at each visit 1
• This is a vision-threatening emergency—gonococcal conjunctivitis can cause rapid corneal ulceration, perforation, and blindness 2, 3

Pediatric Treatment (Non-Neonatal)

Children Weighing <45 kg

• Ceftriaxone 125 mg IM single dose for gonococcal conjunctivitis 2
• For chlamydial coverage: erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses for 14 days (if <45 kg and <8 years) 2
• Children ≥8 years can receive azithromycin 1 g orally single dose or doxycycline 100 mg orally twice daily for 7 days 2

Children Weighing ≥45 kg

• Treat as adults with ceftriaxone 250 mg IM single dose plus azithromycin 1 g orally single dose 2

Neonatal Ophthalmia Treatment

Systemic Therapy

• Ceftriaxone 25-50 mg/kg IV or IM in a single dose, not to exceed 125 mg 2, 1
• Administer intravenously over 60 minutes in neonates to reduce risk of bilirubin encephalopathy 4
• Use ceftriaxone cautiously in hyperbilirubinemic infants, especially premature neonates 2

Hospital Management

• Hospitalization is mandatory for neonatal conjunctivitis 2
• Evaluate for signs of disseminated infection including sepsis, arthritis, and meningitis 2, 5
• One dose of ceftriaxone is adequate for gonococcal conjunctivitis, though some pediatricians continue antibiotics until cultures are negative at 48-72 hours 2, 5

Chlamydial Co-infection

• Test both mother and infant for chlamydial infection simultaneously with gonorrhea testing 2, 1, 5
• If chlamydial conjunctivitis is present, treat with erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses for 14 days 2, 1

Management of Sexual Partners and Contacts

Partner Treatment

• All sexual partners must be evaluated and treated according to adult treatment guidelines 2, 1
• Treatment of sexual partners is essential to minimize recurrence and spread of disease 2
• Both patients and sexual partners should be informed about the possibility of concomitant sexually transmitted diseases 2

Special Populations

• Sexual abuse must be considered in preadolescent children with gonococcal conjunctivitis 1, 6
• Diagnosis in preadolescent children should be documented by standard culture 1
• In many states, sexually transmitted diseases and suspected child abuse must be reported to local health authorities 2

Follow-up Testing

• Retesting approximately 3 months after treatment is advised 1
• For chlamydial conjunctivitis, approximately 20% may require a second course of therapy 1

Common Pitfalls and Caveats

Diagnostic Errors

• Do not rely on topical antibiotics alone—systemic therapy is mandatory 2
• Do not miss the diagnosis by failing to obtain sexual history and appropriate cultures 7
• Gram stain showing intracellular gram-negative diplococci provides presumptive diagnosis, but culture is needed for definitive identification and antibiotic susceptibility testing 2, 1

Treatment Errors

• Do not use oral cephalosporins—they are no longer recommended for gonococcal infections 2
• Do not use quinolones as first-line therapy due to high resistance rates (58% ciprofloxacin resistance reported) 3
• Do not delay treatment—corneal perforation can occur rapidly 3, 8

Antibiotic Resistance Considerations

• All strains remain susceptible to ceftriaxone (100% susceptibility) 3
• Penicillinase-producing strains are common (23% in one series) 9
• Azithromycin or aminoglycoside eye drops are preferred for topical therapy when needed due to quinolone resistance 3

Neonatal-Specific Warnings

• Do not use diluents containing calcium (such as Ringer's solution) with ceftriaxone in neonates—precipitation can occur 4
• Ceftriaxone is contraindicated in premature neonates and neonates ≤28 days requiring calcium-containing IV solutions 4

Infection Control and Prevention

Transmission Prevention

• Hand washing is critical to reduce transmission risk 2
• Modes of transmission include eye-hand contact, sexual contact, and exposure to contaminated droplets 2
• Tonometers must be disinfected with dilute bleach (1:10 sodium hypochlorite) to prevent transmission 2

Return to Activities

• Return to school or work depends on age, occupation, and severity of conjunctivitis 2
• Children can return to daycare/activities after 24 hours of treatment once symptoms begin improving 6